Annual Regulatory Review for GPs

Effective 1st April 2019: This currently applies to GP Practices only

Original Plan in 2018: ONLINE Provider Information Collection

What the CQC said in their Consultation 2

• We will replace the existing provider information return with an annual online information collection. We will ask providers for information every year rather than as part of the preparation for an inspection, and will encourage them to keep it up to date.
• This will be a live online process, rather than a form to collect information in the run-up to an inspection.
• We intend to introduce an online provider information collection in 2018.

New Plan 2019: INTERVIEWS Annual Regulatory Reviews

Every practice rated as Good or Outstanding will be subject to an annual review

• Objective 1: To see if quality of care has changed since the last visit
• Objective 2: To prioritise inspections where there has been greatest change

This review will determine whether an inspection is needed, when the next inspection should be, and which areas they will focus on. Practice Managers and Registered Managers will now have a live telephone interview with their local inspector.

The most fundamental change is that the Registered Manager, usually a GP, is now leading the CQC Inspection, whereas in the past the Practice Manager took most of the burden.

An online form would have been easier to do because:-

• You choose the time and take as long as you want, no pressure
• You can complete in stages, come back to finish when you can
• You can look up gaps and come back to complete
• You can complete as a team

Interviews are not so easy for everyone:-

• You will be anticipating this for 4 weeks
• You have to prepare for a focused one hour of interview
• Not everyone likes to be interviewed like this
• Like preparing for a test, it might be stressful for some

{accordion title="How this will start")

How this will work

1. You will be given a 4 week notice to prepare
2. This will be a telephone interview
3. You will be asked a set of questions
4. The call will last no longer than one hour

You will be asked these questions in the first telephone call

Have you made any changes to:

• where you deliver services from (locations and branches)
• the services you deliver (consider extended access)
• who you deliver it with (consider federations)?

2018 Previous wording

1. The General Practice Forward View, in November 2017 said : We will introduce an inspection interval of up to five years for providers rated as good or outstanding.
2. They also said: We will inspect a proportion of these providers every year in order for them all to be inspected within the period.

2019 New wording

1. Notice issued in February 2019 says: They will only inspect a sample of good and outstanding practices each year with a maximum re-inspection timescale of five years.
2. New Guidance revised in February 2019 says:

• The usual maximum intervals for re-inspecting services depend on your rating (For Good or outstanding this maximum will be 5 years).
• Every year, we will inspect a proportion of providers rated as good or outstanding. This is to make sure that they are all inspected at least once every five years.

Commentary:

• The new wording introduces the term MAXIMUM INTERVAL. Although this sounds like a change, it really seems just a different way of describing the previous terminology "up to".
• The old wording was clear that you could be inspected in less than 5 years but drew your focus to the words "five years" rather than the "up to".
  The new wording is probably more accurate in emphasising the word "Maximum" as this was the intention from the beginning.

Bottom line: Nothing has changed. The inspection interval will be anything from 1 year to 5 years depending on the inspector

What will trigger an inspection

• There has been deterioration in quality
• There has been an improvement in quality

The inspection will focus on the area showing the largest change

Effect on your rating

This will not affect your rating. Ratings can only change at an inspection

Type of inspection triggered

For Good and Outstanding Practices

1. In "most cases" this will be a focused inspection
2. A focused inspection ALWAYS covers the key areas of Well-Led and Effective regardless of the focus
3. They may inspect any of the other five key questions depending on what's on their files

By inference, all other practices will likely be inspected on all 5 key questions

You will be asked some specific questions about what you do at your practice.
Answers should be relatively brief summarising the key points. Many of your answers may be “no” - you can briefly elaborate on these if you choose to.
The call should last no longer than one hour.

DO NOT send any written responses to the questions or any additional documents to the inspector.

Introductory questions

• Are there any issues that have affected your service and how you care for your patients?
  (These could include, for example, challenging circumstances or significant changes to your local population)
• Have there been any changes in the management or leadership of your practice?
• What is your organisation data service (ODS) code?

Safe

1. Have you changed how you keep policies and procedures up to date to make sure patients are safe?
2. Have you changed how you respond to significant events?
3. Have you changed your process for monitoring high risk medicines?
   (You can refer to a particular medicine or to your general management of patients on high-risk medicines)
4. Have you changed how you report and respond to safeguarding concerns?
   (Include all vulnerable groups, both children and adults)

Caring

11. How many patients are on your carers register? (number)
12. Are you doing anything new to identify and support carers?

Well-led

13. Have you changed how you work with local partners to continually learn and improve your service?
    (This could include your patient participation group, clinical commissioning group or local practices)
14. Do you have a plan to improve your service?
15. Have you changed your governance arrangements?

What is governance?

• a systematic approach to maintaining and improving the quality of patient care and service delivery
• led by senior practice members who understand their responsibilities and are accountable for practice performance
• involves all staff members

 Have you changed the way you engage and involve your staff in improving the service?

16. (For example, team away days, staff suggestion box or staff meeting minutes).
17. Has your practice been involved in any innovations or pilots?

Responsive

9. Have you introduced any changes to the service after reviewing your patient survey feedback?
   (These surveys could be the GP Patient Survey or your own practice surveys)
10. Have you changed how you identify and meet the information and communication needs of people with a disability or sensory loss?
    (This relates to the Accessible Information Standard (AIS))

Accessible Information Standard (AIS)

All providers of NHS care or other publicly-funded adult social care must meet the Accessible Information Standard (AIS).

AIS applies to people who use a service and have information or communication needs because of a:

• disability
• impairment
• sensory loss

CQC's original aim was to reduce the frequency of inspections for Good or Outstanding rated Providers to a maximum of every 5 years.
There have beenseveral changes since and there are more in the pipeline as they perfect their new strategy

New Inspection type: Annual Review

• An annual review is carried out, usually by telephone or video call
• The agenda for discussion is based on trimmed down sections of the KLOEs
• Infection control, Safe and Well-Led are the most prominent topics

On-Site Inspections: Visits are scheduled where:-

• CQC’s monitoring information indicates a change in the quality of care
• A provider is part of a larger or complex provider, and a coordinated inspection alongside other services may be more appropriate.
• CQC are undertaking a review of care services in the local area
• Concerns are raised by the public or Local Authorities

Population groups

18. Have you changed how you provide effective and responsive care for any of the population groups (give examples of how you meet their particular needs)?

The six population groups:

• Older people
• People with long-term conditions
• Families, children and young people
• Working-age people (including those recently retired and students)
• People whose circumstances may make them vulnerable
• People experiencing poor mental health (including people with dementia)

Concluding question

19. Is there anything else you would like to tell us?
    (This could be something you do that isn’t covered by our questions)

This is a brand new approach with no guidance or consultation to clarify what this means.
Issues to consider:

• Is this a disclosure statement, are you meant to disclose any failures?
• What if you don't, what is the consequence of non-disclosure
• What exactly does "anything you would like to tell us" mean?

Effective

5. Have you changed how you monitor the quality of your service?
6. Are you using new or existing staff in different ways to provide clinical care to patients (apart from GPs)?
   (These roles could include nurses, healthcare assistants, pharmacists, paramedics, physician associates).
7. Have you changed how you develop and use person-centred care plans?
   (This could include how you work in partnership with specialist nurses, social care colleagues and patients or their representatives)
8. Have you changed how you monitor antibiotic prescribing?

This is conducted by your local designated inspector who you are likely to know already.

It is a relationship and trust building exercise, so maximise this opportunity.

The inspector's attitude is generally friendly and supportive, and not conducted as if it's an interrogation

The two key areas of their focus:-

1. Your Performance - Improvements and decline
2. Any changes to your governance (management and processes)

The inspector will have liaised with:-

• Your CCG
• Healthwatch
• NHS England (possibly)

This is to be expected as they will want to familiarise themselves with any programmes in place and reports received by other organisations

This is what the inspector will have looked at before the review:-

• Your last Inspection Report
• Complaints to them about you
• NHS Choices feedback and reviews
• Clinical and QoF data for GPs
• Insight Reports and performance
• Your web site

GPs are the first to be subjected to this process and the questions asked are clinically focused.
The inspector will be armed with data, both yours and others in the area.

The objective will be to review the following:-

1. Whether you have met targets
2. What you are doing to improve
3. Your level of performance compared to others
4. What initiatives you have taken

Key things to prepare:-

1. Go through your clinical indicators
2. Be familiar with your ratings
3. Be prepared on your own performance Vs. National and local averages

There is no set pattern to this so expect this to be different for each provider.

You will effectively be making a formal statement to an Inspector, so be accurate and truthful.
This is your local inspector so building an honest relationship is vital.
In theory, several of the questions only require a Yes/No answer, however you might want to consider elaborating a little more, even if it just to keep the conversation flowing.

Prepare well for the meeting. A crib sheet will help you focus and keep to the subjects. Make sure your topics follow the same sequence as the CQC questions

Prepare for and have information for ready for the following:

• Clinical Performance  – explain variations and performance both good and bad
• Population groups – variations and performance
• QoF – targets not met and improvement
• Special programmes with your CCG or network

Also useful to have ready:

• Achievements
• Initiatives you are involved in such PCNs, Federations and STPs

About your patients:

What the inspector will also be looking for is whether you have a clear idea and direction about your patient and population needs, together with a clear strategy as to how you meet those needs.

The inspector expects the Registered Manager and the Practice Manager to be available.

They will be inclined to say that no one else should be there, primarily because larger meetings are more difficult to manage and add time

There is no reason why you cannot have other members of the team in the meeting if they have something valuable to contribute, for example:

• Practice nurse
• Another GP
• Assistant manager

If others are in attendance, you should always clear this with the inspector, ask their permission first, explaining why you want this.
Make sure that the persons do not interject, and stick to the topics they were brought in to participate in.

You will get an indication, but nothing definitive as to exactly when your next inspection will be

The answers will be quite generic:

• If all goes well, we expect to visit at least once every 5 years
• Future visits will be focused visits on specific areas, we will tell you what these will be but Well-Led and Effective is always included
• We will do random visits to spot check what we are told is factual
• There might be specific visits if they are alerted to something untoward

A reasonable rule of thumb is that if you have had a recent visit and the interview goes well, the next visit will be some way off.

Even if this goes well, if you haven't been inspected for a few years, the CQC will want to ensure that you have been seen within this 5 year target

EXAMPLE OF A RECENT FINAL LETTER

We have reviewed the information and data available to us about this practice. This information does not indicate there are significant changes to the quality of service being provided since the last inspection.

We will continue to monitor the available information and data about this service throughout the year. Where this information indicates changes or potential changes in the quality of care which may affect ratings, we will review our plans. This may result in our carrying out a further inspection of this service.

----- CQC Inspector -----

To avoid drifting from the subjects and keep the interview on track, you need to control your own narrative and sequence.

1. Prepare a crib sheet to use as an agenda
2. Keep this in bullet point format only - it is just to remind you of the sequence
3. Try and put time guides on topics as a way to prioritise. Like an exam, you don't want to spend too much time on the wrong things
4. Make sure everything is in the same sequence as the questions you have been asked

You obviously have to be well prepared for the standard questions that you have been given, and you will also have your own topics and achievements that you want to put forward. The objective is to get your key points across, and a crib sheet or agenda will keep the conversation on track.

A thorough preparation on each question is essential. This will give you confidence about your own performance and demonstrate to the inspector that you are on top of things.

1. Registered Manager likely to lead so needs to be prepared
2. Address every question asked
3. Review your performance statistics
4. Identify strengths and talk about them
5. Tackle your weaknesses too, show that you are aware and are doing something about it
6. Mention your achievements and aspirations
7. Mention how you are collaborating through networks like PCNs, Federations

Most clients end up with 20 to 30 pages of information in front of them, including data printouts.

Too little is risky and too much is overwhelming, and you have to make a judgement call on what is necessary.
The best way to gauge this is to think in terms of the time available, usually 1 hour and a maximum of 2 hours

The inspector praised the fact that we had provided ALL relevant information in the PIR (the final document was 22 pages long) and highlighted issues (not in too much detail to leave time for discussion) which we thought would be important for the CQC to be aware of.

For instance, our antibiotic prescribing went over the national average in Q1 of 2019-20. So we provided evidence of the steps we are taking to address the issue. The reason for providing a detailed response was to reiterate to the CQC that we continue to provide care in line with the five pillars of patient care - safe, effective, responsive, caring and well-led.

We also listed under each heading what we do which goes beyond the requirements prescribed by the CQC - an enhanced level of care by each specified area.

[Review finished early, in 50 minutes]